A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Assess the client's ability to communicate with the other staff members.

Arrange a meeting with the family to discuss the client's situation.

Administer the client's antidepressant medication as prescribed.

Establish a structured routine for the client to follow.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessing communication ability is important but secondary to establishing a structured routine to address the client's immediate needs.

Choice B reason: Arranging a meeting with the family can provide support but is not the first priority in managing the client's depressive symptoms.

Choice C reason: Administering antidepressant medication is essential but must be part of an overall structured plan.

Choice D reason: Establishing a structured routine helps provide stability, encourages participation in daily activities, and addresses the client's refusal to eat and bathe.

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Correct Answer is A

Explanation

Choice A reason: Monitoring daily sodium intake is crucial because SIADH often leads to hyponatremia (low sodium levels). Keeping track of sodium intake helps manage and prevent complications associated with sodium imbalances, such as seizures or confusion.

Choice B reason: Measuring ankle circumference can help assess fluid retention, but it is not the first intervention. It is more important to address the underlying issue of sodium imbalance.

Choice C reason: Obtaining serum creatinine levels daily can provide information about kidney function but does not directly address the immediate concern of sodium and fluid balance in SIADH.

Choice D reason: Ensuring the client takes a diuretic every morning may be part of the treatment plan, but it is more important to first monitor and manage sodium levels to ensure safe and effective use of diuretics.

A. Activity intolerance. B. Fluid volume excess. C. Ineffective airway clearance. D. Altered nutrition; less than body requirements.

Correct Answer is C

Explanation

Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.

Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.

Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.

Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.

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A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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